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CODING PRIMER ON CONSULTATIONS
Posted on Dec 4, 2007 CODING PRIMER ON CONSULTATIONS
There are more rules developed around Consultation services than most other Evaluation and Management code categories.
Here are some of the reasons consultation guidelines can be so complicated:
1. The definition of a “consultation” is sometimes misunderstood.
2. There are specific documentation requirements for consultative services for both the specialist and the requesting entity.
3. The coding standard for consultations, like new patients, has higher documentation requirements.
Defining the Consult:
Physicians, primary care and specialty alike, generally believe the act of one provider sending a patient to another provider constitutes a consultation. CPT and Medicare have a different interpretation.
Per CPT, a consultation is “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”
In its Transmittal Memo (Pub 100-04 Transmittal 782) published in January 2006 on Consultations, Medicare states that “the intent of a consultation service is that a physician or qualified NPP, or other appropriate source, is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge”.
Whether or not the service is a consultation or a transfer of care is up to the requesting source to define. If the intent of the referral is a “transfer of care”, then the encounter is not a consultation. Based on the Medicare Transmittal Memo, “a transfer of care occurs when a physician or other qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition”.
The service can still be a consult if the consulting physician initiates treatment or diagnostic tests.
Once the consultant has provided the advice, if a decision is made that the consultant will manage the problem, the first encounter can still be reported as a consultation. Subsequent encounters will be billed with office/outpatient codes (99211-99215) is the patient is an outpatient, or subsequent inpatient follow-up codes (99231-99233) if the patient is an inpatient.
Documentation Requirements – for the Consultant:
The documentation guidelines for consultations are commonly known as the “3 R’s”:
· Request
· Render an Opinion
· Report Back
The Request identifies who requested the consultation and why. This can be done in a variety of ways. One is to begin the documentation with a defining statement. For example: “Mrs. Jones presents for evaluation of [X] at the request of Dr. Smith”.
Some consultants write their chart note in the form of a letter back to the requesting source. In that case, the opening statement may read: “Thank you for requesting that I evaluate Mrs. Jones for [X]”.
Rendering an Opinion refers to the consultant’s evaluation, which must include the consultant’s advice.
The Report Back is evidence that the evaluation/advice is being provided back to the requesting source. Per both CPT and Medicare, this is a written report.
Verbiage Pitfalls:
Some words or phrases are considered synonymous with a transfer of care and should be avoided so there is clarity that a consultation has been requested and performed:
Patient referred by Dr Smith Request denotes consult – Refer denotes transfer of care.
· I saw Mrs. Jones today
· Thanks for asking me to see Mrs. Jones
Neither phrase identifies whether the requesting provider intended a consult or transfer of care
PCP: Dr John Smith This just identifies the PCP, it doesn’t document whether the PCP sent the patient, or with what intent
· Thank you for allowing me to participate in your patient’s care.
· I will keep you informed of the patient’s progress Both statements imply transfer of care
Documentation Requirements – for the Requesting Entity
Medicare’s Transmittal Memo of January 2006 includes the following statements:
“Carriers shall instruct physicians and qualified NPPs that the written request for a consultation shall be included in the requesting physician’s or qualified NPP’s plan of care.”
“Carriers shall instruct physicians and qualified NPPs that a consultation request may be verbal however the verbal interaction identifying the request and reason for a consult shall be documented in the patient’s medical record by the requesting physician or qualified NPP, and also by the consultant physician or qualified NPP in the patient’s medical record.”
The previous guidelines indicated that the request could be documented by either party. Now it is also required that the requesting source also have documentation of the request.
Just as specialists have already learned that the verbiage is critical to delineate a request for consultation from a referral for management, requesting entities now need to be more specific in their documentation.
For example, “Send Mrs. Jones to cardiology” doesn’t make it clear whether the physician is requesting a consult or referring for management. A better statement would be “cardiology consult requested”.
Many consulting practices are proactively addressing this issue by developing and using a Consultation Request Form. When the specialist office receives a request to see a patient, a form is faxed to the requesting source to be completed and returned to the specialist. This form identifies the intent (consult or referral) and asks that the requesting source file a copy in their chart.
Coding Standards
A survey done several years ago for primary care determined that while established patients are coded correctly about 54% of the time, new patients are coded correctly only 16% of the time. One reason is that new patient coding has higher documentation standards than established patient coding. The coding standards for consultations are the same as for new patients, so specialists face this higher documentation requirement for both new patients and consultations.
The consultation documentation guidelines require that all three key components (history, exam, medical decision making) must meet or exceed a level in order to code at that level.
For example, if the history and medical decision making support Consult Level 4 (i.e., 99244), but the exam only supports Consult Level 2 (i.e., 99242), then the correct code, based on the key components, is 99242.
The only exception to this is if the code is instead derived based on time rather than key components. This can only occur if more than 50% of the encounter was counseling or coordination of care.
Since the exam is generally the most minimal part of the encounter, generally the level of examination will drive the level of the consultation code.
Upper level consultation codes (99244, 99245, 99254, 99255) all require a comprehensive history. This includes the following:
· Chief Complaint
· 4 or more elements of a history of present illness (or the status of 3 chronic conditions if following the CMS 1997 guidelines)
· Minimum 10 system review of systems
· Minimum 1 element each: past history, family history, social history
The omission of any of the required elements would result in code reduction, in an encounter that might otherwise support an upper level code.
Other Important Consultation Facts:
A consultation can be requested by or performed by a qualified NPP. However, based on Medicare guidelines, an NPP could not perform a consultation on an “incident to” basis.
Medicare will pay for a consultation requested by and performed within the same group practice when the consultant has expertise in a specific medical area beyond the requesting professional’s knowledge. This needs to be clearly documented in the chart notes.
Consultations may be billed based on time, if more than 50% of the face-to-face time with the consultant is counseling or coordination of care.
A consultation can’t be performed as a split visit between a physician and an NPP.
The inpatient consultation may only be reported once per consultant per patient per facility admission.
· CPT eliminated both inpatient follow-up consult codes and confirmatory consult codes several years ago. California Workers Compensation coding guidelines still recognize the confirmatory consult codes (99271-99275), but outside of that arena, CPT directs that patient or family requested second opinions be reported with office visit codes (i.e., 99201-99205 or 99211-99215, as appropriate).
Supporting Tools from GR Medical Management
GR Medical Management has developed several tools that can assist consultants in meeting the documentation guidelines:
· Consultation Request Form
· Sample Consultation Letter
Please contact us for further information.
